Attention Nursing Facility and ICF/IID Provider Types 19 and 68: Tracking Process Is Changing on July 1, 2016 [Web Announcement 1141]

Attention All Providers: Requirements on When to Use the National Provider Identifier (NPI) of an Ordering, Prescribing or Referring (OPR) Provider on Claims [Announcement 850]

Nevada Medicaid and Nevada Check Up News (First Quarter 2016 Provider Newsletter) [Read]

Notifications

Enrollment Termination Frequently Asked Questions (FAQs) [Review]

Enrollment Termination Live Webinars [Review]

If you are a Medicaid provider whose revalidation application has not processed by your termination due date, you will not have access to the Provider Web Portal the day after your termination date. This will prevent any prior authorizations (PAs) from being submitted for approval. Please ensure that you have submitted your revalidation application to Hewlett Packard Enterprise at least 10 business days prior to your termination date to ensure that your application is processed on time.

Scheduled Site Maintenance

During the scheduled site maintenance window the Provider Web Portal will be unavailable. The table below shows the regularly scheduled maintenance window. All times will be in the Pacific time zone.

Monday - Friday
12:00AM - 12:30AM

Sunday
8:00PM - 12:30AM

Nevada Medicaid Forms Can Now Be Submitted Using the Provider Web Portal


On July 6, 2015, HP Enterprise Services (HPES) completed updating all of the Nevada Medicaid forms that are available on this website. These forms have been updated to a format that allows them to be completed, downloaded and saved electronically. In addition, an enhancement has been made to allow some forms to be submitted online using the “Upload Files” page on the Provider Web Portal.


Please see Web Announcement 938 for the list of forms that can be uploaded using the “Upload Files” page on the Provider Web Portal, the types of forms that may not be uploaded, and screenshots and instructions for uploading forms. Upload instructions are also available in the new Electronic Verification System (EVS) User Manual Chapter 8.

Prior Authorization Forms

All prior authorization forms are for completion and submission by current Medicaid providers only.

Form Number Title
FA-1 Durable Medical Equipment Prior Authorization Request
FA-1A Usage Evaluation for Continuing Use of BIPAP and CPAP Devices
FA-1B Mobility Assessment and Prior Authorization (PA), Revised 12/29/10
FA-1B Instructions Mobility Assessment and Prior Authorization (PA) Instructions
FA-1C Oxygen Equipment and Supplies Prior Authorization Request
FA-1D Wheelchair Repair Form
FA-2 Durable Medical Equipment (DME) and Vision History Request
FA-3 Inpatient Rehabilitation Referral/Assignment
FA-4 Long Term Acute Care Prior Authorization
FA-6 Outpatient Medical/Surgical Services Prior Authorization Request
FA-7 Outpatient Rehabilitation and Therapy Services Prior Authorization Request
FA-8 Inpatient Medical/Surgical Prior Authorization Request
FA-8A Induction of Labor Prior to 39 Weeks and Scheduled Elective C-Sections
FA-10A Psychological Testing
FA-10B Neuropsychological Testing
FA-10C Developmental Testing
FA-10D Neurobehavioral Status Exam
FA-11 Outpatient Mental Health Request
FA-11A Behavioral Health Authorization
FA-11D Substance Abuse/Behavioral Health Authorization Request
FA-11E Applied Behavior Analysis (ABA) Authorization Request
FA-11F Autism Spectrum Disorder (ASD) Diagnosis Certification for Requesting Initial Applied Behavior Analysis (ABA) Services
FA-12 Inpatient Mental Health Prior Authorization
FA-13 Residential Treatment Center Concurrent Review
FA-13A RTC Therapeutic Home Pass Form
FA-14 Inpatient Mental Health Services Concurrent Review Request
FA-15 Residential Treatment Center Prior Authorization
FA-16 Home Health Agency Prior Authorization Request
FA-17 Adult Day Health Care Services Prior Authorization Request
FA-17 Instructions Adult Day Health Care Services Prior Authorization Request Instructions
FA-18 Level 1 Identification Screening for PASRR
FA-19 Level of Care Assessment for Nursing Facilities
FA-19 Instructions Level of Care Assessment for Nursing Facilities Instructions
FA-20 PASRR and LOC Copy Request
FA-21 PASRR and LOC Data Correction Form
FA-22 Screening Request for Pediatric Specialty Care Services
FA-24 Personal Care Services (PCS) Prior Authorization | PCS Assessment Forms
FA-24 Instructions Personal Care Services (PCS) Prior Authorization Instructions
FA-24A Coordination of Hospice and Waiver or Personal Care Services (PCS)
FA-24A Instructions Coordination of Hospice and Waiver or Personal Care Services (PCS) Instructions
FA-24B Legally Responsible Individual (LRI) Availability Determination for the Personal Care Services Program
FA-24C Authorization Request for Self-Directed Skilled Services
FA-24C Instructions Authorization Request for Self-Directed Skilled Services Instructions
FA-24T Personal Care Services Recipient Request for Provider Transfer
FA-25 Handicapping Labiolingual Deviation (HLD) Index Report
FA-26 Client Treatment History Report (For Medicaid Orthodontic Treatment)
FA-26A Dental History Request
FA-29 Prior Authorization Data Correction Form

Enrollment Forms

Enrollment forms are for completion and submission only by providers applying for enrollment in the Nevada Medicaid and Nevada Check Up program.

Form Number Title
FA-31A Provider Revalidation Application Packet (Individuals)
FA-31B Provider Revalidation Application Packet (Groups/Facilities)
FA-31C Provider Initial Enrollment Application Packet (Individuals)
FA-31D Provider Initial Enrollment Application Packet (Groups/Facilities)
FA-31E Provider Enrollment Application for Ordering, Prescribing or Referring (OPR) Providers
FA-32 Electronic Funds Transfer Agreement
FA-33 Provider Information Change Form
FA-34 Written Notice of Provider Termination
FA-35 Electronic Transaction Agreement for Service Centers
FA-36 Service Center Operational Information
FA-37 Service Center Authorization
FA-39 Payerpath Enrollment

Provider Training Forms

Advanced classes, taken in conjunction with new provider training classes are recommended for all new Medicaid providers/staff, and as a yearly review for established providers/staff.

Form Number Title
FA-41 2015 Provider Training Registration Website

Sterilization/Abortion Forms

Sterilization/Abortion forms are for completion and submission by current Medicaid providers only.

Form Number Title
FA-50 Nevada Medicaid Hysterectomy Acknowledgement Form
FA-52 Abortion Affidavit (Rape)
FA-53 Abortion Affidavit (Incest)
FA-54 Abortion Declaration (Rape)
FA-55 Abortion Declaration (Incest)
FA-56 Sterilization Consent

Pharmacy Forms

Pharmacy forms are for completion and submission by current Medicaid providers only.

Form Number Title
FA-59 Pharmacy Authorization
FA-60 MAC Pricing Appeal Form
FA-61 Actemra® (tocilizumab)
FA-62 Request for Pharmaceutical Product Review
FA-63 PDL Exception Prior Authorization
FA-64 Cox-II Prior Authorization
FA-65 Synagis® Prior Authorization
FA-66 Amevive® (alefacept)
FA-67 Growth Hormones For Recipients Under Age 21 Prior Authorization
FA-68 ADHD Treatment For Recipients Age 18 And Above
FA-69 ADHD Treatment For Recipients Under 18
FA-70A Psychotropic Agents for Children Age 0 to 5
FA-70B Psychotropic Agents for Children and Adolescents Ages 6 to 18
FA-71 Multiple Sclerosis – Ampyra® Prior Authorization
FA-72 Topical Androgen Agents
FA-73 Suboxone® and Subutex®
FA-74 Makena® (hydroxyprogesterone caproate injection)
FA-75 Hepatitis C Protease Inhibitors
FA-76 Cimzia® (certolizumab pegol)
FA-77 Humira® (adalimumab)
FA-78 Kineret® (anakinra)
FA-79 Orencia® (abatacept)
FA-80 Remicade® (infliximab)
FA-81 Simponi® (golimumab)
FA-82 Stelara® (ustekinumab)
FA-83 Xolair® (omalizumab)
FA-84 Cesamet® (nabilone)
FA-85 Forteo® (teriparatide)
FA-86 Marinol® (dronabinol)
FA-87 Prolia® (denosumab)

Appeals Forms

Appeals forms are for completion and submission by current Medicaid providers only.

Form Number Title
FA-90 Formal Claim Appeal Request

Hospice Forms

The following forms are for the use of Nevada Medicaid Hospice providers.

Form Number Title
FA-91 Nevada Medicaid Hospice Program Action Form
FA-92 Nevada Medicaid Hospice Program Election Notice - Adults
FA-93 Nevada Medicaid Hospice Program Election Notice - Pediatric
FA-94 Nevada Medicaid Hospice Program Physician Certification of Terminal Illness

Emergency Dialysis Case Certification Forms

The following forms are for the use of Nevada Medicaid and Nevada Check Up providers to certify that a non-United States citizen has met the medical conditions to be eligible to receive outpatient emergency End Stage Renal Disease (ESRD) services through the Federal Emergency Services (FES) program.

Form Number Title
FA-100 Initial Emergency Dialysis Case Certification
FA-101 Monthly Emergency Dialysis Case Certification

Nevada DHCFP Forms

The following forms are for the use of Nevada Medicaid and Nevada Check Up providers.

Form Number Title
NMO-7073 Functional Assessment Service Plan
NMO-7073 Instructions Functional Assessment Service Plan Instructions
NMO-7073 (SP) Functional Assessment Service Plan (Spanish)
NMO-7073 Instructions (SP) Functional Assessment Service Plan Instructions (Spanish)
NMO-3430A Nevada DHCFP Serious Occurrence Report
NMO-3430A Instructions Nevada DHCFP Serious Occurrence Report Instructions